Quality Payments – Patient safety report
Quality Payments – Patient safety report
Community pharmacy contractors passing the gateway criteria will receive a Quality Payment if they meet one or more of the quality criteria. One of the quality criteria is:
‘A written safety report (updated since 28 June 2018 i.e. the last review date or covering the last year if not previously claimed) at premises level available for inspection at review point, covering analysis of incidents and incident patterns (taken from an ongoing log), evidence of sharing learning locally and nationally, and actions taken in response to national patient safety alerts; and
Demonstrably, the pharmacy contractor actively identifies and manages the risks at premises level associated with specified look-alike sound-alike errors (LASA) identified from the National Reporting and Learning System (NRLS)**. Demonstrably, the pharmacy contractor has put in place actions to prevent these, for example, physical separation, staff awareness training, visual warnings, tags or labels on shelving, fatigue reduction strategies, enhanced checking procedures for these medicines.
Demonstrably, the pharmacy contractor uploads any LASA incident reports at the pharmacy premises or within any electronic reporting system used by the contractor. In the description of what happened in the NRLS report, the contractor must include the text ‘LASA’ as a unique identifier to facilitate future national learning.
**NHS Improvement top combinations by likelihood of harm caused – propranolol and prednisolone, amlodipine and amitriptyline, carbamazepine and carbimazole, azathioprine and azithromycin, atenolol and allopurinol.’
Click on a heading below for more information.
NHS England guidance
NHS England has published new guidance on the February 2019 review point of the Quality Payments Scheme.
The new guidance should be read in conjunction with NHS England’s previously published gateway criteria and quality criteria guidance:
- NHS England – Pharmacy Quality Payments Gateway Criteria Guidance (published 23rd December 2016); and
- NHS England – Pharmacy Quality Payments Quality Criteria Guidance (published 27th February 2017).
These documents are available on the NHS England website.
Quality criterion points and value
The value of this quality criterion is as follows:
|Total points for the February 2019 review point||20|
|Value of total points||£640-1280*|
*The funding will be divided between qualifying pharmacies based on the number of points they have achieved. Each point will have a minimum value worth £32 and a maximum of £64.
Aim/rationale of this quality criterion
The aim of this criterion is to foster a culture of learning and continuous improvement in every pharmacy with regard to patient safety. It is based on the following principles that have been developed in collaboration with community pharmacy Medication Safety Officers (MSOs) and stakeholders, to support the production of the written patient safety report. These are complementary to the principles of incident reporting which can be found on the Community Pharmacy Patient Safety Group website.
- Incidents to be considered in the report should include errors or near misses that involve medication that have caused patient harm or had the potential to do so. Errors picked up early in the dispensing process or documentation errors would therefore not be included.
- The aim of a pharmacy written patient-safety report is to recognise and support development of a safety culture. In particular, the report should demonstrate continuous improvement through reviewing and reflecting on errors.
- Where errors occur, a proportional response to changes and safety measures should be taken. Contractors should take care that in focusing on one area for improvement, they are not neglecting others.
- Where human intervention is involved, the potential for error exists. Using systems and processes to support staff to make the correct decision or take the right action improves safety. Care should be taken in developing these processes so that they are user friendly, otherwise they risk not being followed correctly, increasing the risk of error.
- The best barriers to error are the simplest and often rely on physical measures.
Error occurs when a complex set of circumstances converge and make it possible. Understanding the relationships between circumstances requires the gathering of information, followed by analysis and reflection. This is why it is important that contractors review errors and share their learning.
How to achieve this quality criterion (includes template reports)
Contractors who claimed for this criterion in the previous declarations will not be able to use the same patient safety report to make a claim in February 2019. For the February 2019 declaration they will need to update their previous report to show how the following details have been updated and refreshed since their previous patient safety report was completed:
- collated incidents and near misses from an ongoing log;
- analysed these and looked for patterns;
- reflected on the learning from these;
- recorded action taken to minimise future risk from repeated errors;
- shared learning (both locally and nationally); and
- evidenced specific actions taken by the pharmacy in response to local errors and national patient safety alerts issued by the Central Alerting System.
In addition to the above, contractors must evidence learning from others on prevention of NHS Improvement’s list of top five look-alike sound-alike (LASA) errors and put in place actions to prevent these, for example, physical separation, staff awareness raising, visual warnings such as tags or labels on shelving, fatigue reduction strategies, or enhanced checking procedures for these medicines. The top five LASA error pairs are:
- propranolol and prednisolone;
- amlodipine and amitriptyline;
- carbamazepine and carbimazole;
- azathioprine and azithromycin; and
- atenolol and allopurinol
This should then be documented in a written patient safety report. Incidents to be included in the report should include errors or near misses that involve medication that have caused patient harm or had the potential to do so. Errors picked up early in the dispensing process or documentation errors would therefore not be included.
Contractors may wish to use the monthly patient safety report template below (in the ‘Resources’ section) to collate and review patient safety incidents each month. Contractors can use the output of these forms to complete their annual report, again, an annual patient safety report template is available below which contractors can choose to use.
Reporting errors to the NRLS
Contractors already have a contractual requirement to report patient safety incidents to the National Reporting and Learning System. This can be done via the e-form following guidance on the PSNC website, and some contractors collate reports via corporate systems, which then report centrally to NRLS. When LASA incidents are reported to NRLS directly or via other systems, in the description of what happened in the incident, ‘LASA’ should be included. This will enable NHS Improvement to search for LASA-related reports and information and learning from such incidents can be maximised.
Copies of patient safety incident reports made by a pharmacy to NRLS or to corporate or other incident reporting systems should be retained by the contractor.
PSNC, the Community Pharmacy Patient Safety Group and NHS Improvement have created the below templates (these have been updated by PSNC and the Community Pharmacy Patient Safety Group for the February 2019 review point), which contractors may choose to use to create their report; these templates are also included in Annex 1 and 2 of the NHS England guidance for the February review point of the Quality Payments Scheme.
A template to collate and review patient safety incidents each month:
A template to complete the annual written patient safety report:
The report does not need to be submitted to NHS England routinely but contractors should ensure that a copy of the report is kept in the pharmacy.
Examples of completed monthly and annual forms can be found below:
Completing the written report
PSNC and the Community Pharmacy Patient Safety Group have published a resource which explains how contractors can use the monthly and annual template patient safety reports to meet the quality criterion and lists questions and examples which pharmacy teams can consider to help them complete the report.
There are several different ways that contractors can share learning locally. This might take the form of a meeting with local general practices to share learning from incidents or near misses, sharing learning with other local pharmacies, a Local Pharmaceutical Committee (LPC), Local Professional Network (LPN) or Local Practice Forum (LPF) event, or sharing via a newsletter.
1. PSNC has developed a Patient safety information page that contains a quick reference guide to patient safety alerts, recalls, advice and guidance relating to patient safety which have previously been highlighted as news stories on the PSNC website and a link to the Medicines and Healthcare products Regulatory Agency (MHRA) monthly drug safety updates.
2. The Community Pharmacy Patient Safety Group has published new resources to help pharmacy teams with discussions around LASA errors. Community pharmacy teams may find these useful when working towards achieving the patient safety report quality criterion of the Quality Payments Scheme.
The resources, which were developed, inspired and informed by the Boots UK ‘Drug of the Month’ posters, include:
- a series of one-pager resources – contains informative LASA medicine dispensing and checking tips; and
- a poster – contains useful background information on LASA errors and summarises some of the Group’s LASA work.
PharmOutcomes support for this quality criterion
Contractors can access support on PharmOutcomes for this quality criterion. This support has been made available to all contractors, as PSNC has agreed to use their licence to provide access to this service.
Contractors can complete their annual patient safety report on PharmOutcomes and a report of this can then be printed out, if required, as evidence of meeting the patient safety report element of the quality criterion. The PharmOutcomes annual patient safety report mirrors the updated annual patient safety report as detailed above.
The patient safety report template can be accessed by logging into PharmOutcomes, selecting ‘Services’; and then ‘Annual Patient Safety Pharmacy Report’ which is listed under the ‘Quality Payment Criteria’ heading.
If a contractor has not used PharmOutcomes before, log in details can be obtained by sending a message to the PharmOutcomes helpdesk. Contractors will need to provide details of the pharmacy, contact information and an email address to issue the login details to.
The declaration process
Contractors will be required to declare through the NHSBSA online declaration page (the portal will go live on Monday 4th February 2019 at 9am and will be available until Friday 1st March 2019 at 11.59pm) that they meet this quality criterion.
Q. What duration of time should my pharmacy’s written safety report cover?
To meet the February 2019 review point, contractors that previously wrote a report for the June 2018 review point must have updated that written safety report since 29th June 2018 (the last review point) to incorporate learnings since that date. Contractors who have not previously claimed for the patient safety report quality criterion, will need to ensure their report covers the last 12 months.
In addition to the above, contractors must also evidence learning on prevention of NHS Improvement’s list of top five look-alike sound-alike (LASA) errors and put in place actions to prevent these. More information is available on the Quality Payments – Patient safety report page.
Q. Is there a template patient safety report that must be used to meet this quality criterion?
A template patient safety report is available on the Quality Payments – Patient safety report page; however, contractors do not have to use this template to meet this quality criterion. If contractors choose to create their own report, they should ensure it includes all the information required by NHS England. Details on the requirements can be found on the Quality Payments – Patient safety report page.
Q. Does completion of the patient safety report replace the need to report patient safety incidents to the National Reporting and Learning Service?
No. Reporting patient safety incidents to the National Reporting and Learning Service (NRLS) is a contractual responsibility and pharmacy teams should continue to do this.
Q. Does the written patient safety report need to be submitted to NHS England?
No. The report does not need to be submitted routinely to NHS England, but contractors should ensure that a copy of the report is kept in the pharmacy.
Q. The quality payment criterion states that a ‘written’ safety report at premises level needs to be available for inspection; does this need to be handwritten or can it be computer generated (typed)?
The report can be either hand written or computer generated (typed).
Q. If we do not have a LASA incident to report to the NRLS, will we still meet the requirements for the patient safety report criterion?
If there is no LASA incident to report, the contractor can still meet the requirements provided they have embedded the process of identifying, reporting and learnings from LASA incidents within their Standard Operating Procedures and meet the other requirements of the patient safety report quality criterion.
Q. Can we continue to submit incident reports via a third party, for example, the National Pharmacy Association rather than direct to NRLS?
Yes. If the third party reports these errors to the NRLS on your behalf, you are not required to report them directly to the NRLS in addition to the third party.
More FAQs on the Quality Payments Scheme can be found on the Quality Payments – FAQs page.